Signing on the Dotted Line: The Rules for Anesthesia Record Signatures

Summary:  Among the many documentation components required on the anesthesia record is the provider's signature. However, many don't realize that there are several attendant rules surrounding this basic task that make this component a bit more complicated than one might initially think.

The delivery man comes to the door with an expensive package. You greet him, and he asks: "Will you sign for this?" You're at the closing for your first house; and, as they hand you a pen and a stack of documents, you say: "I feel like I'm signing my life away." There is no doubt that in the modern world we are requested or required to authenticate certain transactions by way of affixing our name to some type of paper or digital medium. However, this is not just a modern phenomenon. Remember John Hancock's bold signature on the Declaration of Independence, or how about the ancient kings who would depress their signet ring into wet clay or soft wax to produce their official signature and seal?

Use of signatures is an age-old and time-honored practice, which is why it continues to this day. And when it comes to medical records, your signed name carries with it a legal obligation. By your signature, you are averring that the information on the document is true and correct to the best of your knowledge. This sounds simple enough; but, from a Medicare perspective, there are a surprising number of rules surrounding the use of signatures with which the anesthesia provider should become acquainted. The purpose of today's article is to present the rules and recommendations concerning medical record signatures.

Documents Requiring Signature

A medical record that has been deemed such by the facility, such as an anesthesia record, requires a provider signature. This means that progress notes, round notes, labor epidural records, separate reports (e.g., block, invasive lines, TEE, USG), critical care notes, consult reports, and evaluation and management (E/M) reports should all be signed by the anesthesia practitioner who provided the service.

As indicated above, if you create a report that is separate and apart from the anesthesia record—such as a pain block report—you should sign that report. However, if your block note is contained entirely within the signed anesthesia record, it is unnecessary to also sign the block note, as long as the note contains some indication of who performed the block.

Eligible Signatories

Medical records should only be signed by the anesthesia practitioner who provided care on the case connected to that record. In other words, ancillary staff who did not provide anesthesia care should not be signing the record. In the event a scribe is used to document a medical record (such as a consult report) pursuant to the verbal or electronic dictation of the provider on the case, the case provider must still sign that medical record. Under no circumstances should someone sign on behalf of the provider on the patient case.

Furthermore, all anesthesia practitioners on a case must sign the record. Here are some examples of when multiple signatures should be on the anesthesia record:

• * The medically directing anesthesiologist and the medically directed CRNA or AA
• * The provider who initiated care and the provider who came in to relieve
• * The teaching anesthesia provider and the resident or SRNA

Finally, even though the service of a locum tenens physician will be submitted under the name of an absent provider on the claim form, the locum should sign his/her own name on the medical record.

Acceptable Modes of Signing

The Medicare rules provide that an acceptable signature can either be handwritten or electronic. In the case of the latter, you must ensure that it is specifically deemed by the facility as an approved "electronic signature." We recommend you confer with your electronic medical record (EMR) system team to ensure that this capability has been sufficiently programmed within the system. That is, make sure that the system contains the ability to capture the electronic signatures of multiple providers on the case (e.g., medically directed CRNA, relieving providers), rather than having just one "electronically signed by" field.

This also raises an issue as it concerns the hard-copy record. For groups that have a medical direction or teaching model, the record template should have an embedded signature box for at least two providers. For all groups, there should be sufficient room on the record for a relieving provider to also sign. We have several groups that have revised their record template to incorporate multiple signature fields to accommodate these potential circumstances.

The limit of signatures to handwritten or digital modes means that signature stamps are no longer acceptable. There was a time when groups were able to employ this method, but that was changed beginning in September of 2007. The only exception to this rule is where a provider has a physical disability. That is, if you can prove to a CMS contractor that you are not able to sign due to a disability, you may sign using a signature stamp.

Acceptable Form of Signatures

Let's begin with the hard-copy record. The Medicare rules state that the provider's signature must, at the very least, contain the first letter of his/her first name and full last name. We recommend also adding the primary medical credential (e.g., MD, DO, CRNA, AA, SRNA). So, for example, Dr. John Smith would be able to sign, "J. Smith, DO." That is perfectly acceptable. It is not acceptable to sign only using your last name.

This raises another issue for hard-copy records. Using your typical signature—which you might use on your driver's license or on your credit card receipt—is not necessarily going to cut the mustard when it comes to the medical record signature requirements. Medicare has made it clear that the provider's signature must be legible to the extent that it can be matched to the name appearing on the claim form. If "John Smith, DO" is typed out on the claim, but, upon reviewing the record, the payer sees only some indecipherable scrawl where the signature should be, the payer would be unable to verify the record as being signed by you. Potentially, the claim could be denied as a result. "But that's my legal signature," you protest. Yes, we agree, but Medicare requires a legible, readable, verifiable signature—even if it doesn't comport with your "legal" signature. So, we recommend that you either (a) write your name clearly and legibly, or (b) sign as you normally do, but print your name underneath the signature line (a remedy that CMS expressly allows).

For EMR users, this issue of legibility is moot. Typically, the provider's full name and credential appear in a typed format and are thus clearly readable. That's one of the many advantages of a digital record; but you will want to ensure the signature field and functionality align with the government's expectations. According to Medicare, "Digital signatures are an electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage." So, you will want to make sure that the EMR programmers are aware of what constitutes an acceptable and secure electronic signature and have made provisions for such.

If providers abide by the above rules and recommendations, they will avoid possible headaches in the auditing and payment process. If you have further questions on this topic, please contact your account executive or reach out to us at info@anesthesiallc.com.